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DBS Form
Full Name
Date of Birth
Gender
Ni Number
Address History (Must date back 5 years)
Street Address
Address Line 2
City
County / State / Region
Country
ZIP / Postal Code
Date from (Address 1)
Date to (Address 1)
Address 2
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Date from (Address 2)
Date to (Address 2)
Place of Birth
Country
Nationality
Nationality at birth
Surname at birth
Date used until
Previous Names (If applicable you must provide evidence of this – see below)
Full Name
Date From
Date To
Do you have any spent or unspent convictions?
Yes
No
We need 3 forms of ID before we can apply for your CRB. We must have 1 from Group 1 and 2 from group 2 - Please note we MUST have addressed ID! (All utility bills and Statements must be addressed to your current address)
Group 1
Valid Passport (any nationality)UK Driving License (photo card only valid if paper part present)
Group 2
UK P45/P60 Statement (issued within last the last 12 months)Bank or Building Society Statement (issued within the last 3 months)Credit Card Statement (issued within the last 3 months)UK Mortgage Statement from a recognised lenderLocal council rent card or tenancy agreement (issued within the last 3 months)Utility Bill - electric, gas, water, telephone - must be a landline bill (issued within the last 3 months), we can accept more than one utility bill as long as they are from different suppliers)Council Tax Statement (issued within the last 12 months)Benefit Statement, book or card; or original letter from the Department of Work and Pensions (DWP) confirming the rights to benefit – i.e child allowance, pension (issued within the last 12 months)Confirmation from an electoral register search that a person of that name lives at claimed address (issued within the last 12 months)
Name Changes
If you have declared that you have had name changes you must provide us with evidence of this:
Marriage certificate or Civil partnership certificate Birth certificate
Adoption certificate
Divorce, dissolution or annulment papers
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Disclosure Check Consent
The role you are applying for involves substantial access to children and/or vulnerable individuals, and is therefore exempt from the Rehabilitation of Offenders Act 1974. If selected for interview, you will be asked whether you have any criminal convictions, and you will be given the opportunity to discuss any such matters during the interview process.
If you are offered the position, Ever Nurse is entitled—under safeguarding arrangements introduced to protect children and vulnerable groups—to request details of any criminal convictions or pending prosecutions you may have, including those considered “spent” under the Act, along with any cautions or bind-overs. This process is known as disclosure.
You will be required to complete a separate DBS application form, which will be submitted to the Disclosure and Barring Service for processing. Once completed, a copy of the DBS certificate will be sent directly to you, and the employer will be notified of any relevant information contained within.
A disclosure check will not be undertaken without your consent. However, refusal to give consent may result in your job offer being withdrawn. The disclosure of a criminal record or other relevant information will not automatically prevent you from being appointed unless Ever Nurse believes it makes you unsuitable for the role. In reaching a decision, we will take into account the nature of the offence, the time elapsed since it occurred, your age at the time, and any other relevant factors.
All information obtained through the disclosure process will be handled in the strictest confidence and will be securely destroyed once the recruitment process is complete.
Please complete and sign below: I have applied for employment and understand that this role is subject to a disclosure check. By signing this form, I consent to the transfer of my personal data to the Disclosure and Barring Service for the purpose of completing the check. I confirm that the information I have provided in support of this application is complete and accurate. I understand that knowingly providing false information is a criminal offence.
I Conscent
I consent to give EverNurse Recruitment permission carry out online DBS checks both annually or as required
I Conscent
Applicant/Candidate's Email
Date
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